University of Illinois at Springfield International Programs Human Resources Building, Room 52 One University Plaza, MS HRB 52 Springfield, Illinois 62703-5407 Employee Questionnaire for Permanent Residency The following information is needed so that the Office of International Programs can file an application for labor certification with the Department of Labor and an I-140 form (Immigrant Petition for Alien Worker) with the United States Citizenship and Immigration Services (USCIS) in support of your permanent resident application. Please return this questionnaire via e-mail (to intprog@uis.edu or via fax (217 206-6679) as soon as possible. Labor Certification Questionnaire Family Name: First Name: Middle Name: Your current home address: Your current home phone number: Country of citizenship: Country/Province/City of birth: Your date of birth (Month/Day/Year): Current immigration status (e.g., F-1, J-1, H-1). (N/A if not in U.S.): Date status expires (mm/dd/yyyy): Date of your last arrival in the U.S. (mm/dd/yyyy): Current I-94 number (N/A if not in U.S.): Your highest degree: Your major field of study for this degree: Year the degree was completed: Institution where this degree was received: Address of institution: Street: City: State/Province: Country:
Postal Code: Title of job offered to you by UIS: Non-technical description of your job: Salary Offered: per year Your work experience: List all jobs you have held during the past 3 years. Also list any earlier experience that qualifies you for the permanent job opportunity. Add extra pages if necessary. Begin with your current position. Include relevant student employment such as assistantships. 1. Name of employer: 2. Name of employer:
3. Name of employer: 4. Name of employer: ALIEN DECLARATION: The information you have provided on this questionnaire will be submitted electronically to the U.S. Department of Labor in Sections J and K of Form ETA 9089 with your name and the following statement. (Section H of the ETA 9089 describes your permanent job offer.) Please read it.
I declare under penalty that Sections J and K are true and correct. I understand that to knowingly furnish false information in the preparation of this form and any supplement thereto or to aid, abet or counsel another to do so is a federal offense punishable by a fine or imprisonment up to five years or both under 18 U.S.C. 2, 1001. Other penalties apply as well to fraud or misuse of ETA immigration documents and to perjury with respect to such documents under 18 U.S.C. 1546 and 1621. After the labor certification is approved, you will sign this statement on the paper copy which is submitted to USCIS. I agree with this statement Your name: I -140 Questionnaire (information needed in addition to that provided above) Your e-mail address: Your daytime phone number: Social Security Number: We are requesting your Social Security Number in order to complete an application form for the processing of an immigration benefit on your behalf. Certain forms created by the Department of Homeland Security require the beneficiary s Social Security Number if one has been issued. The University will not disclose your Social Security Number without your consent to anyone outside the University except as mandated by law or as required for immigration purposes. Choose one: I will apply for an immigrant visa abroad at an American embassy or consulate. This normally only requires a brief time abroad and overall processing can be faster, but it is riskier. It can be difficult to arrange for the interview to take place at a convenient time, and if any item is not acceptable, a return trip may be required. Few people opt for this method, but it IS an option for you. Location of embassy or consulate: _Country: I will stay in the U.S. and apply for adjustment of status by mail when eligible. Country of last permanent residence abroad: Your foreign address (last known): Does your native language use the Roman alphabet? Yes No (e.g., Chinese, Russian, Arabic, Hebrew). You will need to write your name on the I-140 in your native language. (We will contact you for an appointment). Are you going to file adjustment of status papers concurrently with the I-140? Only possible if your priority date is current. Yes, the following forms will be submitted for me and/or family members:
No Form I-485 - adjustment of status form Form I-765 employment eligibility form Form I-131 advanced parole application Are you in removal (deportation) proceedings? Yes No Has an immigration visa petition ever been filed previously for you? (This could be an I-140 petition filed by another employer, or an I-130 filed by a family member): Yes. On a separate piece of paper, please provide the case number, office location, date of decision (or, if still pending, date of receipt), and, if applicable, the decision (i.e., approved or denied). No Information about your spouse and children (even if they are not applying with you): Name First Middle Last Relationship Date of Birth mm/dd/yyyy Country of Birth Office use only: DOL case no. S.O.C. Code